306003954-5-11-2026-22-AS-WVAS-DTYW38-20260511165532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003954
Report Date: 05/11/2026
Date Signed: 05/11/2026 04:55:44 PM

Document Has Been Signed on 05/11/2026 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PILGRIMS GUEST HOME		FACILITY NUMBER:	306003954
ADMINISTRATOR/ DIRECTOR:	NORMITA/JOSE VIBAR		FACILITY TYPE:	740
ADDRESS:	8431 SANTA BERTA WAY		TELEPHONE:	(714) 995-4020
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 4	DATE:	05/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Normita Vibar (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by care giving staff. LPA explained the purpose for the visit, and Administrator (AD) Nomita Vibar was notified via phone call. AD arrived shortly after to assist LPA with annual inspection. LPA began a tour of the facility and observe the following. AD has an active Administrator certificate valid from The facility is a single storied home with five bedrooms, one of which is a staff room and four of which are resident rooms. The facility is equipped with two bathrooms, and a detached two car garage. LPA observed kitchen area to be clean and free of any mildew and debris. LPA observed a refrigerator, gas stove, dishwasher and microwave located in the kitchen area. All appliances tested operational and appeared in good repair. LPA observed all hazards, sharps and medications to be locked away and inaccessible to residents in care. LPA observed a two day supply of perishable food and a seven day supply of non-perishable food along with a sufficient amount of emergency water on hand. LPA observed all resident rooms to be clean and free of any mildew and debris. LPA observed all reooms to be free of any obstructions and hazards. LPA observed all rooms to be large enough to walk about freely and consist of all required furnishings including a chair, a bed, clean linens in good repair; meaning no strains or tares, a reading lamp, a chest of drawers, and enough storage space to store all personal belongings. LPA observed resident restrooms to be clean and free of any mildew and debris. LPA observed water faucets and toilets to be operational. LPA observed restrooms to have all required furnishings such as a shower chair, slip resistant matts, and grab bars. Hot water temperature tested between 104.3 and 106.5 degrees Fahrenheit. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PILGRIMS GUEST HOME	FACILITY NUMBER: 306003954
	VISIT DATE: 05/11/2026

NARRATIVE

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LPA observed all smoke detectors and carbon monoxide detectors to be in good repair and tested operational. LPA observed the fire extinguisher in the kitchen area to be fully charged but not have an updated service tag attached to it. A deficiency was issued on today's date. LPA observed first aid kit to have all required items in it including bandages, scissors, tweezers, adhesive tape, a thermometer, and a first aid manual.

LPA toured the outside of the facility and observed for the backyard to be large enough to participate in outdoor activities upon resident request. LPA observed an outdoor shaded sitting area, and for the backyard to be free of any obstructions along the side exit routes. Side doors are unlocked and self latching.

LPA reviewed four resident files and three staff files. All files (staff and resident) had all required documents and staff annual training was documented and completed. LPA reviewed P&I with AD and observed all balances to be documented correctly and matched the cash on hand. LPA reviewed medications accompanied by AD and per LPA review all medications are being documented correctly and medications are being administered per physicians orders. No discrepancies were observed.

Based on observations made during today's inspection deficiencies will be issued per title 22 chapter 6 division 8 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/11/2026 04:55 PM - It Cannot Be Edited

Created By: William Vanegas On 05/11/2026 at 04:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PILGRIMS GUEST HOME	FACILITY NUMBER: 306003954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observationthe licensee did not comply with the section cited above as the fire extinguisher located in the kitchen did not have an updated service tag attached to it. Which poses a potential safety risk to persons in care.
	POC Due Date: 05/25/2026
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to obtain an updated inspection tag and get the fire extinguisher serviced as soon as possible. Administrator/Licensee will send proof of correction to LPA before P.O.C due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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